Your Health Matters

In order to provide you with the highest quality of health care, please provide the following information regarding your present state of health and medical history. Please note that all of this information is required to make an accurate assessment of your individual needs and to help you achieve the best possible results. The information you provide is completely confidential.

Please complete the form below

Name *

Name

First Name

Last Name

Email Address *

Date *

Date

MM

DD

YYYY

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

Date of Birth

MM

DD

YYYY

Goals & Expectations

Have you undertaken a fasting or detoxification program previously? *

If yes, what did the program involve?

What are the main reasons you want to do this program? *

What do you think could stop you from achieving your goals? *

How do you rate your present health? *

1 = very poor
10 = excellent

How do you rate your present fitness? *

1 = very poor
10 = excellent

How do you rate your present energy levels? *

1 = very poor
10 = excellent

Medical History

List any surgeries, fractures, accidents, major injuries: *

List any major illness’ you have or are currently suffering from: *

Do you have any amalgam fillings or root canals? *

Have you experienced any trauma to your mouth, including teeth and jaw? If so, explain. *

Who is your regular doctor? *

Date of last physical examination with your doctor:

Date of last physical examination with your doctor:

MM

DD

YYYY

Date of last pathology with your doctor:

Date of last pathology with your doctor:

MM

DD

YYYY

Present Health

Are you pregnant? *

Are you breast-feeding? *

Do you smoke? *

If yes, what is your daily consumption?

Do you drink alcohol? *

If yes, what is your daily consumption?

Do you use recreational drugs? *

What is your blood pressure?

Medical Checklist

Please indicate if you suffer from any of the following conditions and please include severity.

Medications & supplements *

Please list all the prescribed medications (including medications taken regularly or on occasion) and / or supplements (including herbal and vitamin supplementations) that you are currently taking. Please list when you take these and dosage.